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Safety Recommendation Details

Safety Recommendation R-06-008
Details
Synopsis: On December 7, 2003, about 12:12 a.m., central standard time, a UP switching foreman was struck and killed by two locomotives at the UP’s East Yard in San Antonio, Texas. The two locomotives were operated as a single unit under the foreman’s control. He was operating the locomotives from the ground using a remote control transmitter. He usually had a helper. However, the night the accident occurred, the helper position was not filled because of a crew dispatch problem, so the foreman worked alone. He was moving the locomotives from track 32 to train yard track 3, where he was assigned to switch 44 railroad cars. When the accident occurred, the locomotives were traveling about 11 mph and were moving back over the track they had just traversed rather than over the route leading to the destination (train yard track 3).
Recommendation: TO THE UNION PACIFIC RAILROAD: Issue written guidance that emphasizes the importance of using specified wire requirements to the employees responsible for installing and maintaining power-assisted switch machines.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: San Antonio, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04FR004
Accident Reports: Railroad Switching Foreman Struck by Locomotives
Report #: RAB-06-02
Accident Date: 12/7/2003
Issue Date: 6/7/2006
Date Closed: 10/4/2018
Addressee(s) and Addressee Status: Union Pacific (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Union Pacific
Date: 10/4/2018
Response: We are pleased to learn that you have taken measures to improve safety for your maintenance-of-way employees who install and maintain power-assisted switch machines. We note that you have updated the technical drawings of the electrical wiring requirements and added detailed explanations and color pictures to the technical training guide. Accordingly, Safety Recommendation R-06-8 is CLOSED--ACCEPTABLE ACTION.

From: Union Pacific
To: NTSB
Date: 5/8/2018
Response: -From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer: Union Pacific implemented written guidance to its signal and maintenance of way employees shortly after the subject incident, and has been continuing this practice for over a decade now. These guidelines for signal employees and maintenance of way employees are attached hereto for your review.

From: NTSB
To: Union Pacific
Date: 1/25/2018
Response: On September 16, 2010, you wrote that your training department was updating your training manuals, including all drawings, that specify wire requirements and WAGO connectors. However, we have not received any updates on your actions since then, and your most recent response has not addressed this recommendation; rather, you sent us instructions for maintaining and cleaning power switches. Until you submit the recommended guidance, and pending our review of that material, Safety Recommendation R-06-8 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: Union Pacific
To: NTSB
Date: 5/2/2017
Response: -From Rodney Doerr, Vice President- Safety, Chief Safety Officer: Union Pacific's earlier response inadvertently provided only the training and information given to train crews regarding power assisted switches. Union Pacific also implemented written guidance to its signal and maintenance of way employees shortly after the subject incident, and has been continuing this practice for over a decade now. These guidelines for signal employees and maintenance of way employees are attached hereto for your review.

From: NTSB
To: Union Pacific
Date: 3/27/2016
Response: We are disappointed that it has been 10 years since this recommendation was issued, and 6 years since we have received any substantial information from you regarding it. On September 16, 2010, you stated that your training department was updating its ABEX training manuals and drawings in the manual, which specified wire requirements and connecting WAGO connectors in both the text and drawings. However, we have not received updated materials showing that you have taken such action, and your most recent response has not addressed the recommendation. Instead, it seems you have taken Safety Recommendation R 06-8 and applied it to employees who are in the train- and engine operating craft, not to maintenance-of-way (MOW) or signal employees. Although instructions on how to operate power switch machines are necessary for operating employees, train- and engine-operating craft employees do not maintain the power switch, nor is that craft responsible for wiring the switch machine. Until the correct documentation is submitted to us for review, along with an appropriate response addressing MOW and signal employees, Safety Recommendation R-06-8 is classified OPEN--UNACCEPTABLE RESPONSE.

From: Union Pacific
To: NTSB
Date: 12/16/2015
Response: -From Rodney N. Doerr, Vice President-Safety, Chief Safety Officer, Union Pacific: Union Pacific implemented 8.19.1: Radio Controlled Switches. A copy of this rule is appended hereto. There are also specific instructions for the employee regarding these devices included the timetable.

From: NTSB
To: Union Pacific
Date: 10/26/2015
Response: This letter concerns the 12 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the Union Pacific Railroad (UP) between 2006 and 2014. Enclosure 1 is a list of these recommendations; Enclosure 2 is a copy of the correspondence history regarding them. Based on information contained in your February 24, 2015, update, Safety Recommendations R 13 26 and R-14-56 were classified “Open—Acceptable Response,” on August 3, 2015. See Enclosures 3 and 4. We are concerned because we have not received updates regarding action either taken or planned to address the remaining 10 open recommendations for some time?in some cases, for nearly 5 years; for others, not at all. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we request an update as soon as possible regarding your plans or actions to address these 10 remaining recommendations.

From: NTSB
To: Union Pacific
Date: 12/29/2010
Response: The NTSB notes (1) that ABEX has updated its manual to specify wire requirements and connecting WAGO connectors in both the text and drawings and (2) that UP is working with its training department to update its training manuals and drawings. Pending completion of this action, Safety Recommendation R-06-8 remains classified OPEN – ACCEPTABLE RESPONSE. The NTSB would appreciate receiving copies of the updated manuals and drawings once they have been completed.

From: Union Pacific
To: NTSB
Date: 9/16/2010
Response: CC# 201000338: Currently ABEX has updated its manual to specify wire requirements and connecting WAGO connectors in both the text and drawings. The UP is working with our training department in Salt Lake City, UT to update our training manuals and Drawings. Once this is complete we will forward to the Board copies of the ABEX Material and UP Material for your review and the closing of the Safety Recommendation.

From: NTSB
To: Union Pacific
Date: 8/31/2010
Response: The NTSB is pleased that UP plans to require ABEX to update its manual to specify wire requirements and connecting WAGO connectors in both the text and drawings and that, once these revisions are complete, UP will both provide us the updated material to review and update its own manuals and drawings. Pending completion of this action, Safety Recommendation R-06-8 is classified OPEN – ACCEPTABLE RESPONSE.

From: Union Pacific
To: NTSB
Date: 4/8/2010
Response: Letter Mail Controlled 4/27/2010 10:53:00 AM MC# 2100153 - From Roby B. Brown, General Manager Safety: In reference to the NTSB safety recommendation R-06-008 to the Union Pacific Railroad on issuing written guidance that emphasizes the importance of using specified wire requirements to the employee responsible for installing and maintaining power- assisted switch machines. The Union Pacific has reviewed the ABEX Switch Machines manual to ascertain if the manual addresses wire size and the connecting WAG0 connectors in the Machines. Since the Manufacturer does not specify the wire size in the text or in their drawing, it is our intention to require ABEX to update their manual. Once complete the Union Pacific will work with our technical staff in Salt Lake to include the updated information in all of our manuals as well as review and update our drawings.